María Dolors Mas: "Self-esteem is made up of five self-concepts".

Psychologist Maria Dolors Mas talks to us about body dysmorphic disorder and its effects.

The concept of "I", one's own identity, is a psychological element that, by its very definition, seems to be something intimate and non-transferable: the idea that no one knows us as well as we know ourselves is very intuitive, and has a lot of truth to it. However, we cannot forget that the way we perceive the world around us and how others interact with us also greatly influences how we see ourselves.

Psychopathologies such as body dysmorphic disorder are an example of the extent to which our perception of ourselves can get out of hand, to the point of harming ourselves.to the point of harming ourselves. Fortunately, from psychotherapy it is possible to overcome this psychological disorder and other similar ones, as the person we interviewed today, psychologist Maria Dolors Mas Delblanch, knows first-hand.

Interview with María Dolors Mas Delblanch: body dysmorphic disorder and its relationship with advertising, aesthetics and social networks.

María Dolors Mas Delblanch is a General Sanitary Psychologist with many years of experience in therapeutic resources such as cognitive-behavioral model techniques, contextual therapies, and Virtual Reality and applied to psychology. This professional works from child and adolescent therapy and for adults in her office in Badalona, and in this interview she talks to us about the particularities of body dysmorphic disorder and about the psychological alterations linked to it.

How would you summarize what body dysmorphic disorder is, and what differentiates it from other similar psychopathologies?

Dysmorphic disorder or dysmorphophobia is the excessive preoccupation with non-objective defects or imperfections in the face and head, although it also occurs very frequently in other parts such as the thighs, hips, abdomen or arms.

Despite this, the imperfections that cause the greatest aversion for patients are all those areas related to acne such as the forehead, nose or chin, Hair Loss (especially in women and young men), marks, scars...

At the same time, compulsions such as constantly looking at oneself in the mirror, grooming oneself for a long time and excessively before going out in the street and, in some cases, as paradoxical as it may seem, some patients even self-injure (abrasions, scratches) as a form of social avoidance and, in some cases of minors, as a way of obtaining parental authorization for an aesthetic intervention that otherwise they would not have.

All of this obviously causes clinically significant distress and clearly interferes with personal, family, social, academic or work life.

It can be differentiated from other similar disorders such as muscular dysmorphia produced in ED or obsessive-compulsive spectrum disorders such as trichotillomania or dermatillomania. However, it seems quite clear that, for example, in the case of muscle dysmorphia the profile is closer to that of patients with ED in terms of perfectionism, anhedonia, obsessions related to food and/or intense physical exercise. Moreover, in this case, it occurs mostly in men, whereas dysmorphic disorder occurs mostly in women.

Is there a profile of person particularly predisposed to develop this disorder?

Body dysmorphic disorder (BDD) accounts for between 1.7 and 2.5% of diagnoses in the general population, although it is often underdiagnosed because patients are more likely to consult a cosmetic surgeon than a psychologist.

Those who have lived in a dysfunctional parental environment, with little family and/or social support, who have lived through traumatic experiences such as sexual abuse, or who have premorbid dermatological or medical problems are at greater risk of BDD.

Likewise, the patients most predisposed to develop BDD are those with certain personality characteristics such as neuroticism, perfectionism, hypersensitivity to criticism, fear of rejection, low self-esteem and assertiveness, hopelessness and hypochondriasis.

On the other hand, there are socially predisposing factors such as high family expectations that lead to high perfectionism in order to avoid disappointing parental figures. In the same way, current beauty standards and their constant dissemination through advertising, social networks and the media as symbols of success and money are predisposing sociocultural factors.

How does the world of social networks and the constant praise of the canons of beauty on the Internet and in the media influence the appearance of body dysmorphic disorder?

As I was saying, advertising, social networks and the media provide a social representation of an ideal body, basing all their content on very thin, tall, young female models who, therefore, are already assumed to have money and success in life.

As a result, patients with BDD, and especially young adolescent girls, establish a pattern of social comparison with these images with the negative consequences, at all levels, that this entails.

Furthermore, this social representation of an ideal image of models has a direct impact on the patients' perception of their own body and, even more so, of those esthetic problems which, in most cases, would not be objectifiable.

Obviously, there is a lack of critical sense before images that, possibly, have been photographically retouched, but because previously there has not been this critical capacity in those who have the responsibility to allow the publication of images in advertising, media or RRSS as well as a lack of reflection on the part of parents and teachers, at a stage when it is very important to affirm the personality of adolescent girls.

In body dysmorphic disorder is self-esteem damaged in all aspects, or only in terms of self-image?

As we know, self-esteem is made up of five self-concepts: academic/work, family, social, emotional and physical. Although, obviously, the most damaged self-concept is the physical one as it refers to the image we have about our own body and the care of it, the fact that we have intrusive thoughts about possible asymmetries, corrections or imperfections, brings us a deterioration of the emotional self-concept since we are not able to respond to situations in the same way as if we had control over our emotions.

At the same time, compulsions take a long time, which can produce a decrease in academic/work performance and, therefore, affect the academic/work self-concept.

In the same way, many times, family and friends do not understand a disorder that, in most cases, they "do not see" and, therefore, the family and social self-concept is affected since the patient does not feel integrated in his or her social and family group.

What are some of the strategies and techniques used in psychotherapy to help patients suffering from this disorder?

First of all, the patient must come to psychotherapy because this is the most crucial and complicated point. Generally, many patients go first to the plastic surgeon and there the cases of body dysmorphic disorder are not always detected. In cases in which the surgeon does understand the psychopathology, he usually makes the referral but, even so, it is necessary to count on the will of the patient who, in many other cases, may decide to go to another surgeon and to as many others as necessary until he finds the one who will intervene without talking about therapy, if he finds one.

It is also essential to establish a good therapeutic alliance with the patient and, in the case of a minor, it is necessary to choose the right co-therapist for the exposure sessions with response prevention (EPR). Even so, the existence of educational discrepancy can be an interference and, therefore, it will be necessary to have a quality social network.

In some sessions it will be necessary to perform relaxation, for which instead of using classical techniques, which, in the end, do not provide us with enough information about the patient's true anxiogenic state, Mindfulness can be used through Virtual Reality.

Likewise, Virtual Reality can be used for body image distortion. Thus, we have environments such as the dressing room or the restaurant that serve, in the first case, to provide the patient with correct information about her own distorted dimensions.

In this sense, this third generation technique (which we have been using in our office for 10 years) is a perfect substitute for the gradual exposure to avoided situations, as it saves the patient all the inconveniences, since the patient is placed in a warm, empathic and, above all, safe environment, in which to expose herself, in a very close to real way, to her fears.

From what you have seen throughout your experience, how is the process of recovery and improvement of these people, once they have sought professional help?

In general, if the two elements I mentioned above are present: introspection on the part of the patient that her problem is psychological and not aesthetic plus a good therapeutic alliance and following the protocol of a cognitive-behavioral treatment to which third generation therapies such as Virtual Reality or ACT have been added, most patients have a good evolution with remission of the symptomatology.

However, an important point continues to be that patients become aware of the need for periodic follow-ups after discharge. Although the last two sessions are dedicated to relapse prevention, it is important to carry out this follow-up to check whether the results are maintained in the medium and long term, to evaluate the treatment carried out and the maintenance of the behaviors that were established during the treatment.